Being a mom,  Being an MD,  Thoughts

It’s Okay Not to Be Okay (English Version)

Indonesian version please click here.

I am very honored to get good responses on my last posting about mental health in the occasion of world mental health day a couple days ago. My non-Indonesian speaking friends have been asking me, why I only wrote my last post in Indonesian. Since I also want to share my story with my non-Indonesian speaking friends and readers, here it is 🙂

A lot of friends inspired me to write down my very personal experience with burn out and how I finally decided to get a psychotherapy in Germany. Before I begin, I must warn you that this post will be pretty long. But I hope that you’ll all bear with me till the end of the post 🙂 To make this a bit easier to read, I’ll divide this post into three main sections:

  • What is „burn out“ and my personal experience dealing with it.
  • How to get the best therapy, my personal recommendations for friends living in Germany.
  • What to do after the therapy, when you feel ready to get back to your „normal life“.

What is „Burn Out“?

I won’t bore you here with a long scientific explanation.. Why?

  • Because up to date even in the medical world there isn’t any clear definition of „burn out“, unlike other psychological conditions with defined criteria such as „acute depressive episode“ or „schizophrenia“.
  • Secondly because I’m not a trained psychiatrist nor a psychologist.

Very simply said, „burn out“ is a process, where someone continuously works  under enormous pressure/stress until he/she gets exhausted. The pressure/stressor can be one thing or a combination of different things. A very common stressor is for example being a constant caregiver of a sick family member/relative.

There are three symptoms which can characterize „burn out“:

  • Exhaustion: is when people feel drained out both physically and psychologically. It feels like they’re completely out of energy, even after supposedly sufficient rest. Physical sickness such as frequent stomach discomfort, stomachaches, repeating or never-ending infections etc. might appear.
  • Alienation from (work-related) activities: a condition where people find their jobs increasingly stressful and frustrating. It would result in a „whatever“ attitude. They would care less about their jobs, work with less or even no passion at all.
  • Reduced performance: people with „burn out“ are having troubles in their work, at home and also in their social circles. They tend to have negative / pessimistic thoughts. Concentration difficulty and lack of creativity are likely to happen.

Diagnosing „burn out“ can be very difficult, especially because the signs are usually not so specific and can be extremely variable. Often the affected people initially show physical / health disorders and they won’t directly associate their physical disorder with a psychological discomfort. To prevent a false diagnosis, it is very recommended to have a complete physical check up by a doctor.

Before I get to the next point, I would like to write all the symptoms that were present before I „diagnosed“ myself with a „burn out“ which was then „confirmed“ by my psychotherapist. This condition happened around two years ago.

The years 2015 and 2016 were a very challenging time for me. In those years my husband and I faced a lot of challenges, especially in the work area. Due to many reasons we decided to change our job positions and moved from the university in Hannover (Lower Saxony) to the university in Erlangen (a small university town in Bavaria). I used to be a rather ambitious and perfectionist person. My daily life as a resident of the internal medicine department while being a scientist had been very demanding from the beginning on (I started working in the spring of 2012). Although the challenge had not been new for me, I still found myself struggling to find my „equilibrium point“. Even so I had never thought of quitting my job. I was in love in nephrology and I felt at home working in the medical faculty of Hannover Med School.

Our move to Erlangen was pretty much the „trigger“ of my downslide. I had a terrible homesick of  the old nephrology department which had seen me growing from a „nobody“ and Hannover, which had been my home for the past 11 years. Even though the new department in Erlangen was nice, I didn’t find the comfort of „home“. Probably I didn’t give it a fair chance.. I don’t know.. I decided to quit after 4 months working there. My difficulty in adapting in the new department was strengthened by my sleeping problems every time I did night shifts. I realized even more how I found it more and more difficult adjusting to the lack of sleeps after night shifts. This problem was not new to me, but it got more distinct in the new city. This constant lack of sleep along with my overall discomfort in the new place made me exhausted to the bone..

After some thinking I decided to quit my position in the internal medicine and resume my residency in another department. After having a lot of job interviews at various departments I finally decided for a residency in occupational medicine (Arbeitsmedizin).

It became obvious, that changing my residency did NOT solve my problem. Basically I had been loving my job at the hospital to that very time point. I love treating and communicating with patients, coming up with diagnosis and trimming therapy plans. My new job at the occupational medicine was COMPLETELY different than the old one in hospitals. I do enjoy the fact that there are NO MORE night shifts or weekend duties, which can be very dreadful and exhausting. On the other hand, my new job had another set of demands which at some point just as exhausting as the ones in my old job. In the beginning of my time in the occupational medicine I was expected to travel A LOT (usually by car, driving by myself). I was expected to handle a lot of companies all over Bavaria (and that as a bloody beginner).. It became very apparent, that the lack of doctors in Germany does indeed happen in every department, including in the occupational medicine. Overtime and overwork are just as normal as the sun rises in the east..

Eventually all disturbing factors (among others: a very drastic change of my job desk, overwork due to lack of staff and physical exhaustion due to a lot of travelling) became the trigger of my „burn out“. Added with some personal factors and stressors, I eventually gave up by the end of 2016.

It all started with physical disorders.. My body just didn’t want to cooperate anymore and it gave in to some horrific diseases. I had a severe Gastritis , pneumonia, Herpes zoster infection, Impetigo contagiosa (a skin infection which usually happens to children) and some other discomforts (migraine, back pain..) and the list went on. Because of this condition I was forced to have a total bed rest for over three weeks.

Other than physical sickness, there were also a lot of other signs such as:

  • Sleeping disorder. I had both the inability to fall asleep (Einschlafstörung) as well as the inabilty to stay asleep (Durchschlafstörung). This chronic lack of sleep caused me to be very moody and tired all the time. In the end I couldn’t wake up in the morning.
  • Concentration problems and difficulty of focusing / concentrating on one matter. I forced myself to multitask all the time, that eventually I couldn’t finish all the started tasks well.
  • I found it very hard to feel happy and be satisfied. I became a person that took everything for granted and I turned to be less and less grateful. I didn’t have any sense of achievement anymore.. Every success would be shadowed by „the next problem“.
  • I couldn’t enjoy my life and the nice moments happening in my life anymore. Everything felt like a problem.
  • I slowly lost my self confidence and eventually I felt insufficient.. I was never „good enough“. Every time something turned against my expectation, I blamed myself for not being „good enough“.
  • I continuously had negative thoughts, although I used to be a very positive and optimistic person.
  • Slowly I withdrew myself from my social circles. I couldn’t bring myself to meet my friends anymore because I was always tired. And additionally I often saw my life as „very boring“ and not good enough to be talked about.
  • I lost the motivation to engage in any activity, although I usually had a lot of interests in many things. Even my most favorite hobbies such as learning languages, swimming and jogging, salsa dancing or even knitting were neglected.

What a horrific phase and experience.. This process had been going on slowly but steady (probably for over 8 months) until eventually all disturbing factors were united and my whole person just didn’t function as it should anymore.

How to proceed if you have the necessity for a psychotherapy.

Since I’ve been getting questions from some Indonesian or non-German friends living in Germany  of how to get a psychotherapy, I would like to write down my personal experience and also recommendation of how to proceed, if you are in a difficult situation and see the necessity of getting a psychotherapy.

Ideally if you live in Germany, you should have a family doctor/GP (General practitioner/Hausarzt) to consult to in cases of medical issues. Usually a Hausarzt is a physician specializing in general medicine (Allgemeinmedizin) or internal medicine (Innere Medizin). Your GP can initiate therapies on his/her own or he/she will refer you to a specialist according to your case and needs.

You do have the liberty of choosing your own specialists and go directly to them as needed without having to see your GP first. In some cases it might be more convenient but in most cases you could expect a much longer waiting period (sometimes months) to get an appointment for a consultation. Ideally the GP should „filter“ all cases and coordinate the patients depending on the indications and therapy needs. By seeing your GP first, you could avoid the unnecessary exceeding waiting period. Why? Because a lot of cases can be handled directly by a GP or a GP can coordinate your further examination or therapy by getting a better hold of specialists, who might be indicated in your case.

In my case I also connected a GP first, just because I needed to consult someone who could help me coordinate my therapy. But also fortunately (as I am a physician myself) I had some specialists friends, who could help me get my therapy faster.

After three weeks of undergoing antibiotics therapy and a full bedrest, I still didn’t feel well enough. I was still „drained“ and exhausted, even more than the beginning. I just didn’t know how I could get back on two feet and start working again. As you could probably imagine, I had a LOT of works and emails waiting for me during my sick leave. This „moment of truth“ was very intimidating. By the time I opened my email inbox (and saw 300 unopened emails), I just broke down.

I had the worst anxiety attack that I had ever had. Finally I just curled down on the floor and felt incapable of doing anything at all.

I felt completely and utterly helpless. I didn’t know how I even could begin to recharge myself and stand up again. There was only one thing on my mind at that time: I need to get a professional help, either from a psychiatrist or a psychologist. Just another bedrest wouldn’t help me recover anymore. In that acute moment I didn’t think that my family or friends could help me recover. So I decided to pick up the phone and get help.

In this kind of acute situation, it is very important to confirm whether you have suicidical thoughts. If you have this particular thought, it is SO EXTREMELY IMPORTANT to get ahold of your closest family or friend. Ask them to be with you and go together to a hospital with a psychiatry department. If there is nobody you can contact and there is no psychiatry department close by, call your GP or even better go directly to an emergency installation at any hospital. If you are not capable of going at all, call the emergency number (112 for EU). This situation needs to be attended as soon as possible, as it can really endanger your life.

Back to my story.. I didn’t have any suicidal thoughts. Therefore I knew that I needed to get some help fast, but not hyper acute. I called some practices, explained my situation and told them that I would need an appointment within DAYS. Fortunately I was lucky enough to get two psychologist practices who were willing to consult me within 2 – 3 days.

There might be times (unfortunately it happens pretty often), where you don’t get so lucky as I did, because all psychologist practices you have reached out are incapable of admitting new patients. In this situation, especially in Bavaria, there is a coordinating number which can help you find any available psychiatrist or a psychologist in your region for the time being. You can clink this link for more information:  https://www.kvb.de/service/patienten/koordinationsstelle-psychotherapie/.

Once you get an appointment with a psychologist (or a psychiatrist), you will have the opportunity to get to know them better before you decide to undergo a therapy with him/her. For this purpose you will have a total of 6 consultations (each lasts for 25 minutes). On the other hand, the psychotherapist will decide if your condition needs to be attended and if yes, what kind of therapy should be performed.

Before you start with the „real“ psychotherapy, you will have to undergo a physical check up at your GP’s practice. This should be performed to ensure that there ist no other physical underlying cause for your „burn out“ episode. For example: a thyroid disorder could cause malaise or even a depressive episode. Your GP would accompany you throughout the therapy. In any case, either your GP can rule out any physical cause or not,  a referral (Überweisung) for a psychotherapy would be issued. This procedure is needed so that the therapy costs can be covered by the health insurance. Often you also need a sick leave during the beginning of the psychotherapy. For this you would also need your GP as he/she will issue a medical certificate for a sick leave (Krankschreibung).

When both sides (you and the psychotherapist) have agreed on each other (simply said: you like the psychotherapist and he/she sees an indication for a psychotherapy), the psychotherapist would issue an application (Antrag) to the health insurance so that the therapy cost could be covered.

Post-Therapy and Going Back to Work

If your therapy has been going on well and you feel ready to get back to your „real life“, I would recommend you to get ahold of your company doctor (Betriebsarzt), who can accompany the process of your going back to work. When needed and after your approval, the Betriebsarzt can consult your GP (or also your psychotherapist) to ensure a smooth comeback.

Usually workers in Germany have the right to get their full salary during their sick leave, maximum for six weeks. The salary will be paid out normally by the company you work in. If the sick leave goes on longer than six weeks, the company doesn’t need to pay the full salary anymore. In this case there is so called „Krankengeld“, which will be paid out by the health insurance. The amount of Krankengeld is not your full salary.

There is also a defined regulation in the social code of law IX (Soziales Gesetzbuch SGB IX) which states that any worker who is sick for over 6 weeks in a year has the right to be offered a professional/work rehabilitation/reintegration (called betriebliche Wiedereingliederung). Ideally it should be accompanied by a Betriebsarzt for a smoother process.

As an example: there is a rehabilitation process called „stufenweise Wiedereingliederung“. In this model, a sick worker can return to his/her work place gradually (for example one hour/day in the first week, two hours/day in the second week and so on until he/she reaches the original working hours). Until the „Wiedereingliederung“ process has finalized, the worker will still get the „Krankengeld“ instead of his/her full salary. With this process, the worker can focus on coming back to his/her work place without any „work pressure“ while the company isn’t disadvantaged of having to pay a „sick worker“ his/her full salary.

In the modern working world with its continuously increasing work load and pressure, „burn out“ has been a new „trend“ disease. Financially „burn out“ is a „horror scenario“ for a company, since its qualified worker is threatened to be unavailable for work for a long time (weeks or even months). This fact has been a strong drive for a lot of companies to work out a better working condition for their staffs. Once a sick worker is ready to come back, a lot of companies are usually willing to discuss necessary measures openly with the workers. Nevertheless a healthy and productive working situation is one of the most important factors for a successful business.

In my case, I also underwent a process of „stufenweise Wiedereingliederung“. After six weeks of sick leave I contacted my company and asked for a formal process of „betriebliche Wiedereingliederung“.I especially contacted my direct superior, my Betriebsarzt and a representative of the working council (Betriebsrat). Together with these parties I negotiated changes in my working condition to ensure a healthy and productive working condition. I am very grateful, that my superior was very much interested in having me back and ensuring a better possible working condition. Through this process I learned to openly discuss my problems and possible measures to overcome these problems.

A „burn out“ is not a situation which is instantly remedied. It takes time and a lot of effort to get better and to stay better. A psychotherapy is for me a very valuable tool to achieve this goal. Nevertheless it is not the only tool necessary. The recovery success also very depends on your familiar or social environment. The present of supportive family members and friends are essential, especially to maintain your mental stability. As an immigrant myself, I know how important it is to find close friends who can „substitute“ your family (who are far far away).

Another essential thing for me personally is me belief in God. Sometimes in my life „chaos“ I forgot this indispensable matter..

Another alternative tool for maintaining your psychological stability is to join a self-help group. In these groups you can exchange your experience with another people who are or have gotten through similar processes. For more information about self-help groups in Bavaria, you can click this link: https://www.kvb.de/service/patienten/selbsthilfe/selbsthilfestruktur-bayern/?noMobile=true.

I myself have never joined a self-help group. I found writing and sharing my experience openly as a very invigorating tool. Frankly, ever since I have written my experience in this blog I have received so many stories from my friends and also physician colleagues (both non-Germans and Germans) who have been through similar phases.

As a closure of this super long post (thank you for bearing with me!), this is what I can conclude:

To get (and stay) better I have to accept myself as I am. I have to accept the fact that I am tired. Only by accepting my own exhaustion and weakness, I can start learning to be a better person.

The points are:

Accept yourself

Be grateful (of both good and bad experiences)

and stay motivated to be a better person.

I hope that this post can help anyone in need.

Love,

Andina

P.S. This link is one of many understandable and reliable sources of „burn out“:

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/

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